1528165149 NPI number — HUMANA MEDICAL GROUP INC

Table of content: (NPI 1528165149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528165149 NPI number — HUMANA MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HUMANA MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528165149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4621 RUBIO AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-981-0050
Provider Business Mailing Address Fax Number:
818-907-7080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4621 RUBIO AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-981-0050
Provider Business Practice Location Address Fax Number:
818-907-7080
Provider Enumeration Date:
09/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DANIAL
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
818-981-0050

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  20A4720 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0065060 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00065141 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00065141 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00AX47200 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20A4720 . This is a "BSBC OF CALIFORNIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20A4720 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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